That question is perhaps the most common one raised by patients facing a diagnosis of cancer for the first time. There are so many campaigns about how to “avoid” cancer: no white sugar, no chemicals, all-plant diets, regular exercise, don’t smoke, don’t drink. I can see how one can get the impression that if one does all of it, cancer will never touch him or her. Yet, every once in a while, someone comes to my office who drives home the message that all most people can do — and all most clinicians can advise — is risk reduction, not prevention. Such was the case with Laurie (name and details changed to protect patient identity).
Laurie was in her early fifties, the mom of twin girls. She had prided herself on being a health nut—aerobic exercise in the morning, yoga in the evening. She did not eat red meat and didn’t drink alcohol. Her family adopted an organic diet; she even grew her own vegetables. She was proud of her reputation as the “healthiest mom on the block.” She had told me that others in her little town often sought her counsel about how to get healthier.
Then, she found a mass in her breast. At first, she couldn’t believe it, thinking it must have been a blocked duct. However, it grew with time, and eventually, a mass appeared under her axilla.
By the time she was diagnosed she had a 5 cm breast mass and at least two sonographically suspicious nodes. A biopsy confirmed triple-negative breast cancer. She was devastated. Even more, she just couldn’t understand how this happened to her.
“I’ve done everything right — my cholesterol is perfect!” She exclaimed. “I’ve never been sick and neither have my kids. How did I get cancer?!”
I started to answer, but she went on. “Do you think I’ve been exposed to a toxin? Something in the water? Can we check my body for poisons?”
It was clear she was anguished — I got the feeling that she wanted to know more than how this happened — she had to know why this happened. I suspected this was being driven by a desire for a clearer sense of what she did “wrong” to get cancer. Yet, her questions also made me wonder if she needed to know because she wanted to be able to answer the inevitable question of others: “What happened?”
While I am a proponent of healthy lifestyles, cancer screening, and moderation, in general, I have seen how our conversations about risk reduction and cancer prevention can be very distressing to those already diagnosed. “Mammography saves lives,” “One-third of cancers are preventable” — these are messages that resonate and are likely true for populations. But, at the individual level, and for the newly diagnosed patient, they are just not that helpful. So, as I sat there talking with her, seeing her look of worry and concern, I wanted to make sure one point was clear: She did nothing wrong. She did not cause this cancer.
“Living well, being healthy, is and will continue to be so important for you,” I explained. “And I mean, beyond cancer. Think of your heart, for example. Heart disease is still the number one killer in women, after all. For women with cancer,” I continued, “staying active can keep you from getting tired during treatments, minimize the negative impact from medical treatment, and help you recover from surgery.” I went on and reviewed the data about how being healthy is associated with improved survival after a cancer diagnosis.
“I don’t know why you got cancer. We know that most are sporadic, and sadly, healthy people do get cancer,” I continued. “I have had many patients who have healthy lifestyles low in meat and high in green vegetables, some who had kids young and breastfed — all factors that are associated with a lowered risk of breast cancer. I don’t know why they got it, and I don’t know why you did either. If I knew that, I’d win the Nobel Prize. We just cannot explain why cancer happens to any one individual absent of a genetic risk.”
As we concluded our visit and made plans to begin neoadjuvant chemotherapy, I had hoped she was satisfied with my answers and that in some way, I helped alleviate her distress. But as she walked out, she appeared to still be in the shock of the initial diagnosis and fixated on the question, “Why?”
Patients like Laurie reinforce my belief that in our quest to deliver messages on healthy lifestyles, we have made risk reduction and early detection synonymous constructs, which they are not. None of us can guarantee cancer prevention for any one individual patient, short of prophylactic surgeries in the context of a high risk of cancer (for example, women with a BRCA mutation in whom oophorectomy and mastectomy are options). I think we need to be more consistent and clear that the steps we take today can lower our chances of getting cancer not prevent it. I think framing issues like this would have helped Laurie and others like her. Cancer is a hard enough diagnosis to hear, and blaming one’s self for it is certainly something we should help our patients avoid.
Don S. Dizon is an oncologist who blogs at ASCO Connection.
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